ABSTRACT: This commentary on Nassir Ghaemi's The Rise and Fall of the Biopsychosocial Model is offered as an elaborative piece, briefly touching on tangents and tributaries suggested by the book itself. Ghaemi's text is immersed in the work of a sort of theoretical brush removal, clearing thereby a path for a vision of what psychiatry (and, by extension, the enterprise of psychotherapy) might one day conceivably become. The present piece is a sympathetic reverie on an intellectually impressive and ethically principled work. Nietzsche's Thus Spake Zarathustra is its literary touchstone, William Arrowsmith's notion of "creative criticism" its inspiration and attempted goal.

What is great in man is that he is a bridge and not an end: what can be loved in man is that he is an overture and a going under.
Friedrich Nietzsche Thus Spake Zarathustra

I experienced an unanticipated pleasure recently upon rereading Nassir Ghaemi's The Rise and Fall of the Biopsychosocial Model.(1) I read it while traveling back and forth to Vietnam to celebrate the Lunar New Year. It is the Year of the Dragon over there, a big year and deal. I had promised the Karl Jaspers Society of North America a written version of the discussion around Nassir's book in which I participated last winter here in Boston but had been too over-extended to get to it. Nassir's work deserves attention, however, and not only from his colleagues in psychiatry. Further, the request seemed somehow to mirror internal processes. I have found myself; significantly as a consequence of discussions I have had with Nassir during the several years I have known him, thinking about Jaspers again after a very long hiatus. My journey to the East (a part of the world where, much more so than here, destiny is granted its inexorable place) has made possible this time with what, I perceive now with greater clarity than before, is an inspiring vision of what the profession of psychiatry, at its noblest, might conceivably be; also, by extension, how its sister discipline of clinical psychology might one day evolve.

"Character is destiny," we read in one of the fragments of Heraclitus that have come down to us through the corridors of time. Character is, indeed, one of the things I would like especially to get across. At a certain point, our books and journal articles, our preoccupations and ideals, disclose something about who we are and what drives us—something about character. ("Your true self," Nietzsche once mused, "does not lie deeply concealed within you but immeasurably high above you, or at least above what you usually take for your ego.")(2) Nassir is an unusually literate man with interests in all sorts of things. He must surely be one of psychiatry's most impressive "thinkers," and, given what I suspect is an oftentimes rather hardheaded colleagueship, can be forgiven when, here and there, one brushes up against just the faintest hint of ostentation. He is given to trying out different stylistic approaches so as to get at the state of affairs and pretense of things, thereby making way for an envisioned future. The result is a strong and insistent voice, one informed by clarity of thought and broad erudition, qualities increasingly rare at this moment in time. Ghaemi's circumspect discussion of theory and Zeitgeist—and, further, what I focus on especially here: the place of the humanities—is impressive, a consequence of a disciplined and principled mind. Also, for want of a better term, of character.

The Pace of Art

Early on in TheRise and Fall, we find a graphic representation of the manifold practical and theoretical shortcomings associated with the biopsychosocial (BPS) model that typify mainstream psychiatry. A circle denoting what we might take, hypothetically, as "total understanding" contains four embedded and intersecting points of observation (medical, behavioral, psychological, and social) associated with a catholic-appearing yet confused conception of things that Ghaemi is striving hard to upend. The diagram, it may be seen at a glance, reveals significant areas of functioning and experience that are accounted for by none of the extant means of approach. It is a visual depiction of the presuppositions of BPS-like eclecticism and, further, its evident shortcomings. So much territory remains unexplored, a vast unknown perhaps unrecognized by alternately myopic or muddled observers even when one or more perspectives are conjoined. The standard ways of knowing come up woefully short, whether due to this or that fundamentalist exclusion or a cavalier faith under the guise of professional largesse in having, eclectically, covered the whole.

This illustration, interestingly, recalls what Nietzsche calls "the circle of science" about which he writes in The Birth of Tragedy (originally published, it is not irrelevant to recall, as The Birth of Tragedy Out of the Spirit of Music):

Science, spurred by its powerful illusion, speeds irresistibly toward its limits where its optimism, concealed in the essence of logic, suffers shipwreck. For the periphery of the circle of science has an infinite number of points; and while there is no telling how this circle could ever be surveyed completely, noble and gifted men nonetheless reach, e'er half their time and inevitably, such boundary points on the periphery from which one gazes into what defies illumination. When they see to their horror how logic coils up at these boundaries and finally bites its own tail—suddenly the new form of insight breaks through, tragic insight which, merely to be endured needs art as a protection and remedy.(3)

An astonishing passage reminding us just how well it is possible to write about even difficult and nuanced things and, also, the inevitability of art. Nietzsche's metaphor influenced Jaspers (emphatically, one of the pantheon of lofty spirits informing Nassir's vision and ideals) himself in a quite profound way. Jaspers speaks to the void ("sinking into nullity") and also possibility ("the supreme possibility of freedom even in the face of impossibility"),(4) elaborating Nietzschean boundary or limit situations that throw one into shipwreck and dread for better or worse. It is the paradoxical tension between polarities that is noteworthy: "both alternatives," Jaspers counsels, "are possible."(5)

It is altogether fitting, however unexpected, that Ghaemi speaks thoughtfully to and admiringly of the place of art in approaching richer understanding of human wellbeing and malaise. Biological approaches to the easing of the mind's excessive travail constitute an often appropriate, even necessary, response; they do not, however, explain or treat all, something we cannot reasonably expect them to do. The same may be said for psychological and sociological perspectives. Art, though many may have still not heard the news, is also a means of apprehending what would go otherwise overlooked and has even its therapeutic aspects as well. Here, then, to flesh out just a bit more this theme, a few eloquent reveries on the place of the arts by a handful of artists/poets of astonishing introspective capability and eloquence:

Art flies around truth, but with the definite intention of not getting burnt. Its capacity lies in finding in the dark void a place where the beam of light can be intensely caught, without this having been perceptible before.(6) Franz KafkaThe Blue Octavo Notebooks

Art, like science, is a means of assimilating the world, an instrument for knowing it in the course of man's journey towards what is called "absolute truth" ... Art could be said to be a symbol of the universe, being linked with that absolute spiritual truth which is hidden from us in our positivistic, pragmatic activities.(7) Andrey TarkovskySculpting in Time

We possess art less we perish of the truth. Friedrich NietzscheThe Birth of Tragedy

Such words and conceptions may seem a bit abstract to those not yet "within hearing distance"(8) and, hence, far removed from the spheres of concern of the workaday psychiatrist or psychotherapist. We are, however, quoting creative spirits of staggering native psychological genius whose works continue to startle and inspire literature, thought and art long after their respective lives and deaths. The quote by the Russian auteur Tarkovsky (Ingmar Bergman often cited him as the most important filmmaker of our time) suggests, as Nassir too repeatedly does, multiple ways of knowing. (Pluralism, urges Ghaemi incessantly through his books, not eclecticism.) It suggests, further, a potential crossroad between art and the potential for change we tend to associate with psychotherapy. Federico Fellini, another filmmaker of genius, reflects on this intersection between art and psychotherapy in the following way:

I am not a "therapeutic" artist, my films don't suggest solutions or methods, they don't put forward ideologies. All I do is bear witness to what happens to me, interpret and express the reality that surrounds me. If, through my films ... people come to an equal awareness of themselves, then they have achieved the state of clear-sighted detachment ... which is essential in making new choices, in bringing about [change].(9)

The artist, both filmmakers suggest, proceeds by intuition/imagination even more than reason, a point that Nassir, too, explicitly develops and underscores.

We note, then, at the very least the benefit of an open yet discriminating mind. William James (also very high up in Nassir's pantheon of exemplars) upon visiting his former lab student Gertrude Stein many years later in Paris was thrilled upon entering her flat to find all those Picassos, Cezannes, and Matisses hung on the walls. "He looked and gasped," Stein later recalled, "I told you ... I always told you that you should keep your mind open."(10) James understood with especial clarity both the place and limitations of science and, in this regard, practiced exactly what he preached. For her part, Stein, patroness of modern literature, art and the avant-garde, was similarly open to learning from manifold quarters, with James her most admired instructor. "William James," she once exclaimed, "taught me all I know" (PN 155). Here the complementariness of ways of knowing (each in its own place and informing the others) is the essential thing.

The Place of Music

Out of the spirit of music. It is noteworthy that Nietzsche honors music in such a way in his earliest book. Nietzsche himself was an accomplished musician, improvisation being for him its most sublime expression. Even after madness had overtaken his cognitive faculties, his ability to extemporize at the piano persevered. ("That music may dispense with words and concepts," he exclaimed, "–oh what advantage she derives from that fact.") In his book, Nietzsche elaborates upon this esoteric theme:

Language can never adequately render the cosmic symbolism of music, because music stands in symbolic relation to the primordial contradiction and primordial pain in the heart of the primal unity, and therefore symbolizes a sphere which is beyond and prior to all phenomena. Rather, all phenomena, compared with it, are merely symbols: hence language, as the organ and symbol of phenomena, can never by any means disclose the innermost heart of music; language, in its attempts to imitate it, can only be in superficial contact with music; while all the eloquence of lyric poetry cannot bring the deeper significance of the latter one step nearer. [BT 55-6]

"Language," echoed Nietzsche's near-contemporary William James, "works against our perception of the truth."(11) The word, to put it more cautiously, is by no means the only thing. Socrates, we recall, awaiting execution hears a voice that comes to him several times in a dream: "Socrates, practice music"—a mysterious nocturnal message not lost upon Nietzsche who discerned cracks in the philosopher's estimable life.

We do not, of course, mean to suggest that psychiatry forego reason or science for fine art or musicology but, rather, to uphold the multiple paths of inquiry into what it is to be human. "Beyond dogmatism," muses Ghaemi, "there is another possibility: perhaps there are two kinds of knowledge—or twenty—each of them valid in its own realm" (RF 161). I have always found it a disquieting thought that both Freud and Jung, the gaping distance between them notwithstanding, shared an almost total lack of feeling for music; it seemed, in fact, a deficiency of which each man was even proud. For me, this strikes a cautionary note. There are places within the heart music, for example, reaches where the most grandiloquent theory or finely honed thought simply does not.

John Coltrane, a jazz artist of staggering depth and decency, cited Einstein as his greatest hero. It was Einstein's conception of relativity that especially intrigued him. Possessed by deeply spiritual yearnings and proclivities, he inquired assiduously into Islam, Jewish mysticism and Eastern thought. (Nassir, it is interesting to note, has a bit of Sufism in his family genealogy, something about which he is, I think, especially and justly proud.) Coltrane was fanatically aligned with the mission of speaking directly through music in a spiritually salutary way. In his book on Coltrane, New York Times music critic Ben Ratliff writes of

the story of a concentrated listener, opening jazz up to influences beyond its periphery ... There is a thoughtful musician's establishing of a new kind of intellectual seriousness in jazz ... There is a mystic's keen sensitivity for the sublime, which runs like a secret river under American culture—the meditative and semierotic aesthetic of endurance, of repetition, of ecstatic religion ... And, to judge from his song titles alone, his playing suggested an explorer's mapping of some sort of terra incognita—meditative inside, astrological outside.(12)

Especially intriguing is the way in which such "big mind" concerns commingle with the microscopic complexities of multiphonics and Coltrane's obsessive explorations of scales in his famous sheets of sound—"the next thing," Ratliff wryly observes, "to geekdom." Complementarity/plurality rather than blithe eclecticism, to repeat.

In a letter to a friend concerning Aaron Copland's Music and Imagination, a book that friend had lent him, Coltrane writes gracefully:

If I may, I would like to express a sincere hope that in the near future, a vigorous investigation of the materials presented in this book and others related will help cause an opening up of the ears that are still closed to the progressive music created by the independent thinking artist of today. When this is accomplished, I am certain that the owners of such ears will easily recognize the very vital and highly enjoyable qualities that exist in this music. I also feel that through such honest endeavour, the contributions of future creators will be more easily recognized, appreciated and enjoyed, particularly by the listener who may otherwise miss the point ... because of inhibitions, a lack of understanding, limited means of association, or other reasons.(13)

Misapprehension, inhibitions, limited means of association: attributes of the conventional mindset zealously protecting its familiar and well-trodden turf. Transposed into other realms, Coltrane might have easily been talking about orthodox responses to Nassir's work.

The Place of Humor

There is a Jewish expression that goes like this: "Man thinks, God laughs." This notion eliciting the limits of logic and the place of humor also bears scrutiny. Walter Benjamin, the renowned literary critic, once commented that the key to an understanding of Kafka (the writer who he felt had above all others "mapped out the spiritual territory of the modern condition") could be found in the comic aspects of Jewish theology.(14) A strange and counter-intuitive assertion given the Czech writer's extreme anxiety and despair and his recurring terror at the prospect of going mad: Kafka's diaries, letters and fiction by no means suggest a happy camper. Still, there is something to Benjamin's idea. Although Kafka neither completed nor published any of the three novels he wrote, his friends reported that when he begin to read from one of them aloud he could not get through even a single paragraph without bursting into uncontrollable laughter. There is, after all, something absurdly funny about this nocturnal writing seamlessly suspended between dream and reality. Kafka's darkened visions have, irrepressibly, hilarity about them as well.

Nietzsche, too, decries the leaden "spirit of gravity" that typifies, overwhelmingly, the scholastic scene. (15) "Scholarly oxen," he chides (NP 311). So much academic writing, let us admit it, is not exactly pleasurable to read. At a certain point, we deny the limits of reason in taking ourselves too seriously. ("One does not kill by anger," taunts Nietzsche's mouthpiece Zarathustra, "but by laughter.") Think of Chaplin's Modern Times and The Great Dictator. In a world that simply does not add up, humor may well be one of life's most salutary elixirs. It is intriguing and not wholly surprising that those individuals who have peered most persistently into the void (Allen Wheelis, perhaps, in our field; Woody Allen, certainly, in his) are often the ones who are funniest. Humor as a worthy response to life at the limits?

Even in the titling of chapters, Nassir manifests a penchant, even panache, for humor, provocation and irony: "The Perils of Open Mindedness," "So Many Theories, So Little Time," "Riding Madly in All Directions," Pharmacology Awry." "Don't bother consulting the Talmud to understand the Krebs cycle in cells," he informs us; "don't try to use the second law of thermodynamics to explain the creation of Adam." There is an unexpected lightness of expression throughout such an intellectually and theoretically rigorous work that fosters accessibility of oftentimes somewhat dense terrain. This is no small feat and quite unusual in a book such as this. Intellectual rigor conjoined with fanciful language and wit: the tension of opposites and paradox of things, once again. Remember Coltrane? We are still speaking to matters of style and character.

Existential Psychotherapy

And it seems to me that what we might call existential psychotherapy has much to do with life at the limits. Individuals seeking existential psychotherapy have reached not infrequently the boundary points of their known worlds of experience. These boundary points, one might say, symbolize the borderlands of equanimity and knowledge, places of unknowing that—in contrast to the reigning approaches—are given to a different sort of scrutiny and invoke a different category of response. What happens when the frail human specimen approaches the limits of her or his system and stares into the cosmic expanse or cosmic void? "Horror," suggests Nietzsche, as now "logic coils up" and "bites its own tail." The problem here is not biological or behavioral or social but, rather, ontological and, hence, pervasively human. Psychopharmacology will not be of use save the amelioration of "symptoms" (fear, trembling and despair) that are themselves the consequence of greater purview rather than psychiatric illness per se. Jaspers sets forth concisely the human dilemma:

Deprived of his world by the crisis, man has to reconstruct if from the beginning ... There opens to him the supreme possibility of freedom, which he has to grasp even in the face of impossibility, with the alternative of sinking into nullity. [MM 194]

The risks are great, the precipice daunting. It would be a great boon if the providers on hand did not aggravate things by placing the one who suffers on too narrow or, alternatively, eclectically sagging a Procrustean bed.

A client of mine, a college student, publishes an essay about psychotherapy and encounter, articulating at the very onset the extreme exasperation associated with having been met hitherto with only ill-fitting methods of approach and response:

By the time I met, Dr. Mendelowitz, I'd spent months sitting in identical rooms while the doctors tried to figure it out. These were rooms with two chairs, and some random imitations of Rothko paintings on the wall, more like a business office instead of a safe haven. Every week I would sit across from a different doctor and discuss my ever-shifting moods. Whenever I did finally say something to them, I'd look up and I'd find these strangers. They all had faces as blank as a new canvas, with nothing discernible behind their features.

These sessions felt like a trap, and the doctors all said the same thing. I was depressed and bipolar. It was as elementary as that ... a simple diagnosis treatable with the right medication ... I was hesitant to begin something I could depend on for the rest of my life. I knew there were other alternatives. I thought learning various religions would help but this course ended when I couldn't bring myself to believe in anything. It just didn't feel right ... I fell into further despair, the darkness closing in on me. The horizon looked menacing and foreboding and I gave in to everything the psychiatrists said. I began taking Seroquel and it seemed like I was on the right track, but my existential questions didn't stop. Once I even went into the woods to be alone, much like an animal does when it senses its own death. I took a folding knife with me and I sat on a log, staring off into nothingness.(16)

Setting aside for the moment the choice of psychopharmacological agent (the antipsychotic was, in fact, prescribed alongside a mood stabilizer and antidepressant), we discern in retrospect that the various clinicians erred in their assessment. Allegedly racing thoughts were here not an indication of mania but, rather, the pronounced self-inquiry and agitation of a sensitive young man quite legitimately (given the unavailability of suitable interlocutors) nearing the end of a rope. In the quotation that begins this commentary, Nietzsche suggests that we must stretch ourselves to become who we are, bridging an abyss such that counsel—at times mere accompaniment—may be more-or-less requisite. We can all remember the euphoria experienced when we first met our own mentors, professional guides, so to speak, through our personal and disciplinary struggles and travails.

What is interesting is the manner in which the truth-taking stare into life at the limits (the periphery of known treatments and worlds) to which Nietzsche and Jaspers properly point catalyzes in the client a renewed willfulness in finding something else or more. It is upon running into Camus's essay The Myth of Sisyphus in a bookstore (serendipity may have also its place) that he is motivated once more to seek more meaningful help:

It was then that I knew that the traditional form of counseling wasn't working for me. I needed to find an alternative form of treatment. I had heard of "existential psychotherapy" through books I had read. I decided to look it up online. Only one psychologist came up. [SL 109]

And, so, a young man pushed very nearly to the limit steps back from the ledge in order to find a way through inward turbulence and outward misconstrual:

Our first meeting stands out in my mind vividly. He was a tall, slender man, with a tranquil face and a joyful disposition. His voice was soft, and peaceful. He asked me to come into his office. The first thing he said wasn't the typical, "So, what can I do for you?" All he said was, "Tell me about yourself." [SL 109]

It is noteworthy that the client's resolve in persevering in his search for effective help occurs on the brink of hinted thoughts, even an implied plan, of suicide. Suicide may be a final desperate act when avowed experts and supports, effectively, do not hear. It is the paradoxical tension, once again, between existential polarities we duly note: both alternatives are possible.

Nassir's writing investigates doggedly the overreaching of things: of those practitioners of BPS eclecticism and the various psychotherapies fully convinced of the correctness of their likewise circumscribed epistemologies and techniques. (Nassir has expressed to me privately his impression that bipolar disorders are under- rather than over-diagnosed, and I can well believe this is true. At the same time, his writing points in a quite sophisticated way to states of being/suffering that might be better met with more existentially-oriented approaches to psychotherapy if only such approaches could be expediently found. He is inspired here, once again, by Jaspers, and Leston Havens too.) We are here dealing, to repeat, in realms that have little to do with biology or conventional approaches to psychotherapy, though it is important that biological etiologies be considered (something that existential-humanistic psychologists are, unfortunately, often loathe to do) even as one moves into these vaguer yet sometimes more fitting ontological realms. Ghaemi is arguing, the astute reader gradually discerns, for rarified approaches to both disciplines—disciplines that, while irremediably interrelated, may be far more different from one another than one might think. It is an auspicious sign that the client clings to his own words—"despair" rather than "depression"; "nothingness"; "menacing and foreboding horizons"—in articulating his distress. Clearly, this is not science, though there is no reason whatever why existentially-oriented psychotherapists should not be more interested in the biological domains.

Martin Buber, who saw human beings as creatures of the "between," speaks of "healing through meeting."(17) This is not, to be sure, a scientific category and even existential-humanistic psychotherapists effect it less convincingly or often than one might expect or hope. Still, there is something elevating in this poetic idea. Nassir's devotion to and continued honoring of his own mentors is both moving and instructive in this regard; I can, in turn, recall many conversations with my own mentor very nearly verbatim decades later—so profound was the encounter no less than the underlying need by which it had been engendered. Really, it is a not wholly dissimilar need that characterizes the client:

It was the first time I felt like I could let my guard down. A weight lifted from my shoulders.

When I left his office, I felt overjoyed and uplifted ... My gut was no longer churning. For the first time in a while I could look at my surroundings without a care in the world. I could just be. The experience was serene. I was a tabula rasa waiting to experience the world. [SL 110]

This is by not to suggest that "healing through meeting" is the alpha and omega of change or that it is always experienced quite like this. Still, though, it happens, and here the client is a skillful enough writer to set down his feelings and thoughts. It is the encounter that catalyzes the courage to persevere and eventually change. Can empathy be taught, as Nassir suggests? I am not so sure. Ultimately, we are speaking to matters of attunement, qualities that may be more a function of sensitivity and character than learning. Certainly, though, irrespective of one's starting position, movement should be possible.

And it strikes me that Nassir implies, indeed pulls for, this kind of psychotherapeutic endeavor—a call to conscience not only for psychiatrists but also for psychologists just as well. In these realms, what Nietzsche and James and Rank and May call "will" comes inexorably into play. Responsibility (response-ability) is a foundational existential tenet in the struggle to fashion something worthy of one's prospects, world and self. My client expresses this insight in his closing lines as he anticipates the end of the therapeutic alliance and the continuation of his own journey through life:

Dr. Mendelowitz introduced me to a while new world. He helped me regain control. When I feel the impulse to cut, I go to a quiet place and close my eyes. I think about all the texts I've read and what they've taught me. My head becomes clear. I know Dr. Mendelowitz won't always be there for me, but I'll always be here for myself. Someday my mentor will fade from my sight. Everything is finite, and nothing lasts forever. We will always struggle and I know I will struggle in the future, but I can never let the darkness get in the way of La Dolce Vita: The Sweet Life. [SL 111]

The final reference, for those who may not know, recalls Fellini's famous film, La dolce vita, which, while depicting the vacuously self-indulgent lives of hangers-on and celebrities in the limelight (the word paparazzi was coined in this iconic work), considers also their dwindling prospects for finding a way forward or out.

And, so, we are returned one final time to what psychiatrists and psychologists have to learn form artwork of genius—a point that Nassir underscores emphatically as well. A few closing quotes, then, of existential insight by the Italian maestro Fellini:

I believe ... that what I care about most is the freedom of man, the liberation of the individual ... from the network of moral and social convention in which he believes, or rather in which he thinks he believes, [but] which encloses him and limits him and makes him seem narrower, smaller, ... even worse than he really is. If you really want me to turn teacher, then condense it with these words: be what you are ... discover yourself ... To me life is beautiful, for all its tragedy and suffering ... I am moved by it ... I do my best to share this way of feeling with others. [FF 157-8]

"Be what you are," "discover yourself": these are, patently, Nietzsche's exhortations as well.

Understand clearly, then, what our disciplines have to learn from artists and their art. Note, too, how artwork may itself assuage loneliness as it opens eyes and stirs passions, even pointing beyond itself to the prospects for encounter, even meaning, once again.

Our trouble, as modern[s], is loneliness, and this begins in the very depths of our being. No public celebration or political symphony can hope to be rid of it. Only between man and man . . . can this solitude be broken, only through individual people can a kind of message be passed, making [us] understand—almost discover—the profound link between one person and the next. [FF 61]

Fellini is hinting at boundary points and the void beyond and to the possibility that inheres not only in art but human connection, also, as "protection and remedy." A great relationship," writes Buber, "breaches the barriers of a lofty isolation, subdues its strict law, and throws a bridge from self-being to self-being across the abyss of dread of the universe."(18) Effective psychotherapy may well effect movement, in the words of William Barrett, from "closed to open worlds,"(19) a therapeutic outcome specified on no insurance form I have ever seen.

Vision Beyond the Cave

Nassir presented me with a copy of Rise and Fall of the Biopsychosocial Model after a grand rounds lecture at Tufts Medical Center he arranged for me to present on the topic of existential psychotherapy. I was apprehensive about just who my audience would be and whether its members would be within earshot concerning the things about which I would speak. I incorporated Niezsche's Thus Spake Zarathustra (the book of which Nietzsche seemed to have been especially proud) as a sort of talisman for my talk; it is, after all, a profound and poetic work about the challenges and possibilities that inhere in self-renewal and change. Nietzsche's prophet seeks neither obeisance nor system but, rather, individuals who are strong enough to take it all in and then proceed, self-creatively, on their own. ("This is my way," urges Zarathustra; "where is yours?") We are each of us, so to speak, the way; the charismatic leader is merely one of a multitude of conceivable pointers or guides. "Step our of your cave: the world awaits you like a garden," exhorts Zarathustra to his disciples; "All things want to be your physicians."

A line like this was, perhaps, not particularly well suited for my audience. Still, Zarathustra himself learns early on that some of us come for the few, not the many. The provision of a something lighter weight for the masses will be someone else's role in the in the cosmic drama or game in which we all make our cameo appearances as we play out our transient roles upon a foreshortened stage. ("One must harbor chaos," exhorts Zarathustra, "to give birth to a dancing star.") The prophet points to courage, possibility, virtue, and play. Nietzsche, in the end, is no prototype Nazi but, rather, a provocateur of genius who urges moral and imaginative fiber as we go deep within our personal narratives in order to create something different and uniquely our own.

Inside the jacket of my copy of The Rise & Fall is the following inscription by the author himself:

Nassir signs his name beneath these lines. His signature is intriguing yet patently illegible. Do we require more proof than this that the man is a really good doctor? Nassir is a kind of Nietzschean Übermensch or, as the Jews like to say, simply a Mensch. He urges the self-overcoming of professions—certainly his own, and, by extension, I would argue, also mine. He stretches himself in a way that few of his colleagues, or mine, ever do: A vision beyond the cave. This effort is prodigious, indeed admirable, irrespective of eventual outcome. I am quite pleased to have run into this guy.

Author's Note

William Arrowsmith, scholar, critic and translator of classical literature, once wrote an extraordinary homage to Michelangelo Antonioni in which he expressed his hope for an eventual "poetry of criticism," "a criticism designed to do more than report and judge its artistic object, but rather to respond to it antiphonally, to illuminate, even celebrate it." "We need," he went on, "not an autonomous criticism, as theorists seem to advocate, but a criticism that ... tells us how that work does to us what it does; how, at its ultimate limits it may even make the work better by completing it in the act of comprehension."(20) It is this spirit of esteem and interlocution that I offer this "critique" of Nassir Ghaemi's second book: as a sympathetic and supplementary response inspired by the original work.